405850254-5-10-2023-29-AS-DCHZ-CRQ4KT-20230510191051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850254
Report Date: 05/10/2023
Date Signed: 05/10/2023 07:11:38 PM

Document Has Been Signed on 05/10/2023 07:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	INGLESIDE PARK		FACILITY NUMBER:	405850254
ADMINISTRATOR:	ALLAN, BRETT		FACILITY TYPE:	740
ADDRESS:	9220 MOUNTAIN VIEW DRIVE		TELEPHONE:	(805) 460-7040
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY:	15	CENSUS: 11	DATE:	05/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Brett Allan, Licensee/Administrator		TIME COMPLETED:	07:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Chavez made an unannounced 1-year required annual visit to the facility above. LPA met with Brett Allan, Licensee/Administrator, Melissa Copelan, House Lead, and Nikole Daugherty, Administrator, and explained the purpose of the visit. LPA requested a staff roster, a resident roster, emergency and disaster plan, and documentation of quarterly emergency drills. Documentation of quarterly emergency drills was not available. House Lead says a fire drill was done a few months ago but cannot recall the exact dates of previous drills. Deficiency cited. LPA toured the facility with the Licensee and House Lead and the following was noted: LPA observed the license posted, licensing reports, personal rights, non-discrimination notice, LTCO poster, CDSS Complaint Poster, Bill of Rights and Right to Residential Council. The facility has 10 bedrooms and 6 bathrooms, a kitchen, dining room, living room, courtyard in the front and back of the facility, and storage garage. Medications are kept in a locked room next to the kitchen. Physical plant was check for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, and all were in good condition. The facility maintains a comfortable temperature. The facility provides a working telephone for resident use. Smoke and carbon monoxide detectors were tested and operational. Fire extinguishers (2) are located in the hall by room 1 and the room in front of medication room and were last inspected 12/10/22 and are charged in the green. There are no issues with Fire Clearance. LPA observed cleaning supplies and disinfectants in an unlocked cabinet below the kitchen sink. The cabinet has a lock, however, staff say it is broken. LPA also observed laundry detergent in the unlocked laundry room. Technical violation issued. The facility has cameras inside and outside throughout the facility. Living and dining room furniture were also checked for functionality and condition. The living room and dining room are clean, safe and sanitary. Continued on 809-C.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: INGLESIDE PARK	FACILITY NUMBER: 405850254
	VISIT DATE: 05/10/2023

NARRATIVE

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Courtyard of the facility has outdoor furniture, with a covered shaded area for residents in the back yard. There are no bodies of water on the premises. There is plenty of outdoor lighting available for the safety of the residents. External gates have latches and working properly.
Kitchen was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. The refrigerator and freezer were in compliance with temperatures.
Resident rooms have beds with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, nightstand and enough lighting for each resident. There is enough linen available to change weekly or more, if need.
Bathrooms were checked for cleanliness and proper operation. The hot water temperature measured between 112 F and 118 F degrees in resident bathrooms. Residents have a sufficient amount of supplies for personal hygiene. Soap, paper towels and toilet paper are provided by the Licensee. Grab bars are secured in toilet and shower areas. Showers have non-slip bottoms or mats.
Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for current Medical Assessments with TB results, Current Appraisal Needs and Service plans, and signed Admission Agreements. Dental contact information is not currently listed on residents' emergency records. Technical violation issued. Planned activities are offered to residents in care.
Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 5 staff for criminal record clearances/associations, Health screening with TB results, current First Aid/CPR, and Administrator Certificate. Two out of five records reviewed indicate two staff were not associated to the facility. Deficiency cited. TB records were not available in two out of five staff records reviewed. Deficiency cited. First aid certifications were not available in two out of five staff records reviewed. Five out of five staff records reviewed indicate that there is insufficient documentation showing that staff met the minimum hours of required annual training. Deficiency cited.
Medications are in a centrally stored and locked room next to the kitchen, including over-the-counter medicines. Medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the residents’ doctor. Proper medication dispensing instructions are followed. The first aid kit has all proper items and is current.

Exit interview conducted, deficiencies cited, technical violations issued, and the report and appeal rights given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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